Cognitive Behavioral Therapy (CBT) is a type of psychotherapy in which the patient is instructed on different possible ways to interpret events and behaviors which can be used to lead to more positive outcomes in his/her life. CBT was originally created for use with depression, but its use has been shown in most mental illness including schizophrenia. Earlier in this blog (see October 4) for two articles that are about using CBT in acute schizophrenia. This study is another that was designed to determine if there was a benefit to the CBT style of training or if Psychoeducation (PE) was more or less effective. Psychoeducation is a method of teaching families and patients about their psychiatric disease.

In this study, the authors conducted a randomized comparison meaning that patients were assigned either to CBT or PE randomly, so as to limit potential biases in group placement for a desired effect. Also, this study utilized psychotherapy groups while the other papers addressed using CBT on an individual basis. Using groups allows for a more practical approach that could be applied in non-research settings in the community. CBT is often limited by the need for an individual therapist per patient which makes it very time consuming and expensive. Utilizing groups would make it more cost effective for more patients.

This is how the authors describe the CBT modules that they taught, “The intervention included 16 sessions in 8 weeks. Sessions followed a semi-structured format and lasted between 60 and 90 min, interrupted by a 5 - 10 min break. Treatment involved the following elements: (i) assessment and engagement (sharing information about voices and delusions, models of psychosis), (ii) improving self-esteem, (iii) formulation of key-problems, (iv) interventions directed at reducing the severity and the occurrence of key problems, (v) relapse prevention/keeping well. The following specific CBT strategies were used: formulation, guided recovery, symptom monitoring, exposure/focusing strategies for managing voices, hypothesis/reality testing, reframing attributions, rational responding, coping strategy enhancement, distraction techniques, role play, anxiety management, depression and self-esteem work, medication compliance/motivational interviewing, schema work, relapse prevention and keeping well strategies.” These are all techniques that one can use to increase insight and work on finding ways to minimize disturbance from various symptoms and also increase adherence to treatment regimen. The PE curriculum was described as, “The program included eight sessions in 8 weeks. Sessions followed a semi-structured format and lasted between 60 and 90 min, occasionally interrupted by a 5 10 min break. It covered the following topics: symptoms of psychosis, models of psychosis, effects and side-effects of medication, maintenance medication, early symptoms of relapse, relapse prevention.”

After six months, the authors report that patients who received CBT had a statistically significant decrease in rehospitalizations compares to the PE group. However, both groups showed improvement over the course of the six month follow-up. In fact, there was not significant difference between the groups with respect to general symptomatology. This might have been because the groups were too small to detect a difference statistically or may relate to the make up of the studied population. It is also possible that the group CBT, while cost effective on the larger scheme, may not work as effectively as originally thought. Despite this equivocal aspect to the results, the overall benefit appears to be promising for CBT and the group effect was ultimately minimal.

Overall, the potential benefits from CBT far outweigh the risks. Patients demonstrated fewer hospitalizations while working in their groups. It is important to note though, that the PE group was similar to the CBT in most other measures. This may be also because simply having a group to be responsible towards may have been helpful for the subjects. Ultimately, CBT would be nice to have for most/all patients (and many people in the non-schizophrenia population.) Its possible effectiveness in the group setting is especially promising for those in heavily populated areas, where it can be difficult to fine, much less afford, a therapist for long enough to do any work. While there is still much more room for research, and this paper did have a few small methodological flaws, it does present a cogent argument for using CBT in conjunction with antipsychotic medication as a way to help people with schizophrenia to improve.